Medical Policy Updates
Blue Cross and Blue Shield of North Carolina Medical Policy Update for January 4, 2011
| Medical Guidelines | Reason for Update |
|---|---|
| Ambulatory Event Monitors | CPT codes 93230, 93231, 93233, 93235, 93236 and 93237 deleted from Billing/Coding section. (mco) |
| Anterior Eye Segment Optical Imaging | Added new CPT codes 92132, 92227, 92228. Removed deleted CPT code 0187T. (lpr) |
| Aqueous Shunts and Devices for Glaucoma | Added new CPT codes 66174, 66175, 0253T to Billing/Coding section. Removed deleted CPT code 0177T. (lpr) |
| Bioengineered Skin | Added new product information for Matristem®, Hyalomatrix®, Endoform Dermal TemplateTM, and Theraskin®. Added the following codes to reflect the 2011 HCPCS coding updates: C9367, G0440, G0411, Q4117, Q4118, Q4119, Q4120, and Q4121. Deleted code Q4109. (mco) |
| Bioimpedance Devices for Detection of Lymphedema | CPT code 0239T added to the Billing/Coding section. (adn) |
| Cardiac Hemodynamic Monitoring in the Outpatient Setting | New policy implemented as a combination of policies titled, "Non-Invasive Left Ventricular End Diastolic Pressure" and "Non-Invasive Measurements of Cardiac Hemodynamics in the Outpatient Setting". Cardiac hemodynamic monitoring in the outpatient setting is considered investigational. Reviewed by Senior Medical Director 9/2010. Notice given 9/28/10 Effective date 1/4/11. Removed codes 0104T and 0105T. (mco)New policy implemented as a combination of policies titled, "Non-Invasive Left Ventricular End Diastolic Pressure" and "Non-Invasive Measurements of Cardiac Hemodynamics in the Outpatient Setting". Cardiac hemodynamic monitoring in the outpatient setting is considered investigational. Reviewed by Senior Medical Director 9/2010. Notice given 9/28/10 Effective date 1/4/11. Removed codes 0104T and 0105T. (mco) |
| Cough Stimulating Device | Added new HCPCS code A7020 to Billing/Coding section. (lpr) |
| Dental, Reconstructive Services | Policy extensively revised to include additional indications based on updated benefit language. Extensively expanded the "When Covered" section for clarity. Removed the following statement previously stated as a covered indication; "For dental extraction related to radiation therapy." This is not considered reconstructive services. Removed the following statement under the "When Not Covered" section; "For reconstructive procedures delayed without medical cause beyond the immediate post-injury period (2 years)." "Policy Guidelines" section revised to discuss dental services that are not considered reconstructive. Specialty Matched Consultant Advisory Panel review 1/2010. Senior Medical Director review 6/2010 and 8/2010. References added. Notification given 9/28/2010. Effective date 1/4/2011. (lpr) |
| Extracorporeal Photopheresis as a Treatment of Graft-versus-Host Disease, Autoimmune Disease, and Cutaneous T-Cell Lymphoma | New policy written. -Extracorporeal photopheresis may be considered medically necessary as a technique to treat chronic graft-versus-host disease that is refractory to medical therapy. Extracorporeal photopheresis may be considered medically necessary as a technique to treat late-stage (III/IV) cutaneous T-cell lymphoma. Extracorporeal photopheresis may be considered medically necessary as a technique to treat early stage (I/II) cutaneous T-cell lymphoma that is progressive and refractory to established nonsystemic therapies.|| -Extracorporeal photopheresis is considered investigational as a technique to treat acute graft-versus-host disease or chronic graft-versus-host disease that is either previously untreated or is responding to established therapies. Extracorporeal photopheresis is considered investigational as a technique to treat either the cutaneous or visceral manifestations of autoimmune diseases, including but not limited to scleroderma, systemic lupus erythematosus, rheumatoid arthritis, pemphigus, psoriasis, multiple sclerosis, or diabetes. Extracorporeal photopheresis is considered investigational as a technique to treat early stage (I/II) cutaneous T-cell lymphoma that is either previously untreated or is responding to established nonsystemic therapies.|| Reviewed with Medical Director 8/31/2010. Notification given 9/28/2010. Policy effective date 1/4/2011. (btw) |
| Group Visit (Shared Medical Appointment) Guidelines | New policy implemented. Group visits (shared medical appointments) may be covered if the following criteria are met: 1) The patient is an established patient already enrolled in the practice, 2) The group visit is disease or condition specific, however, this does not preclude coverage of group visits that are designed to address aspects of multiple chronic conditions for patients with co-morbid conditions. 3) Patient attendance is completely voluntary; patients are entitled to have individual appointments as needed, 4)Adequate facilities and time are provided for group visits, 5)Appropriate staff members are maintained (mco) |
| Hematopoietic Stem-Cell Transplantation for Multiple Myeloma | Specialty Matched Consultant Advisory Panel review 11/29/2010. No change to policy statement. (btw) |
| Hematopoietic Stem-Cell Transplant for Non-Hodgkin Lymphomas | Added the following to the "Description" section; "Related Policies: Hematopoietic Stem-Cell Transplantation for CLL and SLL and Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis and Waldenstrom Macroglobulinemia." Removed the following statement from the "Benefits Application" section; "Services for or related to the search for a donor are not covered.” No change to policy intent. "Added the following to the "When Not Covered" section; "Note: Small lymphocytic lymphoma may be considered a node-based variant of chronic lymphocytic leukemia (CLL) and is considered in policy, Hematopoietic Stem-Cell Transplantation for CLL and SLL. Lymphoplasmacytic lymphoma/Waldenstrom macroglobulinemia is considered in policy, Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis and Waldenstrom Macroglobulinemia." Updated "Policy Guidelines" section. Specialty Matched Consultant Advisory Panel review 11/29/2010. References added. (btw) |
| Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis or Waldenstrom Macroglobulinemia | Policy name changed from Bone Marrow Transplant for Primary Amyloidosis or Waldenstrom Macroglobulinemia to Hematopoietic Stem-Cell Transplantation for Primary Amyloidosis or Waldenstrom Macroglobulinemia. "Description" section revised. Changed wording in policy statement and throughout the policy from "high dose chemotherapy with stem-cell support" to "hematopoietic stem-cell transplantation" as appropriate. Removed the following statement from the "Benefits Application" section; "Services for or related to the search for a donor are not covered." No change to policy statement. Updated "Policy Guidelines" section. Specialty Matched Consultant Panel review 11/29/2010. References added. (btw) |
| Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases | 1/4/11 Policy name changed from "Bone Marrow Transplant for Autoimmune Diseases" to "Hematopoietic Stem-Cell Transplantation for Autoimmune Diseases". Specialty Matched Consultant Advisory Panel review 11/29/10. No change to policy statement. (btw) |
| Hematopoietic Stem-Cell Transplantation for Chronic Myelogenous Leukemia | Specialty Matched Consultant Advisory Panel review 11/29/2010. No change to policy statement. (btw) |
| Hematopoietic Stem-Cell Transplantation for CLL and SLL | Specialty Matched Consultant Advisory Panel review 11/29/2010. No change to policy statement. |
| Hematopoietic Stem-Cell Transplantation for CNS Embryonal Tumors and Ependymoma | Specialty Matched Consultant Advisory Panel review 11/29/2010. No changes to policy. (btw) |
| Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer | Policy name changed from "Bone Marrow Transplant for Epithelial Ovarian Cancer" to "Hematopoietic Stem-Cell Transplantation for Epithelial Ovarian Cancer." Specialty Matched Consultant Advisory Panel review 11/29/2010. "Description" section revised. No change to policy statement. Removed statement indicating; "Services for or relating to the search for a donor is not covered." "Policy Guidelines" updated. References added. (btw) |
| Hematopoietic Stem-Cell Transplantation for Hodgkin Lymphoma | Specialty Matched Consultant Advisory Panel review 11/29/2010. No change to policy statement. |
| Hematopoietic Stem-Cell Transplantation for Solid Tumors of Childhood | Policy name changed from "Bone Marrow Transplant for Solid Tumors In Childhood" to "Hematopoietic Stem-Cell Transplantation for Solid Tumors in Childhood". "Description” section revised. Removed statement, "Services for or related to the search for a donor are not covered." From the “Benefits Application" section. Reformatted the "When Covered" and When Not Covered" sections. Removed reference to "bone marrow transplant with stem-cell support" and changed to "hematopoietic stem-cell transplantation." throughout policy as appropriate. Added additional indication under the "When Covered" section to include, "initial treatment of high-risk Ewing's sarcoma initial treatment of high-risk Ewing's sarcoma". Updated "Policy Guidelines". References added. Specialty Matched Consultant Advisory Panel review 11/29/2010. (btw) |
| Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors in Adults | Policy name changed from Bone Marrow Transplant for Miscellaneous Solid Tumors in Adults to Hematopoietic Stem-Cell Transplantation for Miscellaneous Solid Tumors In Adults. Specialty Matched Consultant Advisory Panel review 11/29/2010. "Description" section revised. Reference to bone marrow transplant with high dose chemotherapy changed to hematopoietic stem-cell transplantation throughout the policy as appropriate. Removed statement in the "Benefits Application" section which indicated; "Services for or related to the search for a donor are not covered." No change to policy intent. References added. (btw) |
| Hematopoietic Stem-Cell Transplantation in the Treatment of Germ Cell Tumors | Specialty Matched Consultant Advisory Panel review 11/29/2010. No change to policy statement. References added. (btw) |
| Hyperthermic Intraperitoneal Chemotherapy | Added new 2011 CPT code, 96446 to "Billing/Coding" section. Removed deleted code, 96445. Added "Related Policies: Hyperthermia Therapy" to "Description" section. (btw) |
| Immune Globulin Therapy | Added new HCPCS codes J1559 and J1599 to Billing/Coding section. Also added HCPCS code J1460 due to deletion of J codes J1470-J1550.(lpr) |
| Immunization Guidelines | Added new CPT codes 90460, 90461, 90654. Added new HCPCS codes Q2035- Q2039. (lpr) |
| Implantable Bone Conduction Hearing Aids | Added HCPCS code L8693 to the Billing/Coding section. (adn) |
| Infertility Diagnosis and Treatment | CPT codes 0058T and 0059T reinstated. Added to Billing/Coding section. (adn) |
| Injectable Clostridial Collagenase for Fibroproliferative Disorders | Codes J3490, J3590, J9999 and C9266 deleted from policy. New code specific to injection of Clostridial Collagenase (Xiaflex) added to Billing/Coding section: J0775. (mco) |
| Orthotics | Added codes E1831, L5961 and L4631 to Billing/Coding section to reflect 2011 HCPCS code changes. L3672 and L3673 will no longer be valid HCPCS codes effective 1/01/11. (mco) |
| Radiosurgery, Stereotactic Approach | Added new CPT codes 61781, 61782, 61783 to Billing/Coding section. Removed deleted CPT code 61795. (lpr) |
| Skilled Nursing Services | Added new HCPCS codes G0162, G0163, G0164 to Billing/Coding section. (lpr). |
| Sleep Apnea: Diagnosis and Medical Management | Added CPT codes 95800 and 95801 to the "Billing/Coding" section. Also deleted codes 0203T and 0204T. (adn) |
| Smoking Cessation Therapies | Added new HCPCS codes G0434, G0436, G0437 to Billing/Coding section. (lpr) |
| Surgery for Femoroacetabular Impingement | Billing/Coding section updated to read: "Effective January 1, 2011, three new codes have been added for arthroscopic surgical treatment of hip – 29914 for femoroplasty (ie, treatment of cam lesion), 29915 for acetabuloplasty (ie, treatment of pincer lesion), and 29916 for labral repair. Code 29915 cannot be reported with the hip arthroscopy codes for chondroplasty (29862) or synovectomy (29863). Code 29916 cannot be reported with 29915, 29862 or 29863. This service was previously submitted with 29999. With specific codes now available, services should not be submitted using the unlisted code."(mco) |
| Tocilizumab (Actemra) | Added new HCPCS code J3262 to Billing/Coding section. Removed J3590. (lpr) |
| Transcatheter Heart Valve Implantation | 1/4/11 New policy implemented. Transcatheter Heart Valve Implantation is not covered for any clinical indication including mitral or aortic valve replacement or by any approach. This includes percutaneous/endovascular access or by transapical/transventrical access.(mco) |
| Transcranial Magnetic Stimulation | CPT codes 90867 and 90868 added to the Billing/Coding section. CPT codes 0160T and 0161T deleted. (adn) |
| Ustekinumab (Stelara) | J3490 and J3590 deleted from policy. New code specific to injection of Ustekinumab (StelaraTM) added to Billing/Coding section: J3357. (mco) |
| Vagus Nerve Stimulation | Added new 2011 CPT codes; 64568, 64569, and 64570 to "Billing/Coding" section. Removed deleted code, 64573. (btw) |
| Evidence Based Guidelines | |
| KRAS Mutation Analysis in Cancer | Added new 2011 CPT code, 88363 to "Billing/Coding" section. (btw) |
| Ventricular Assist Devices and Total Artificial Hearts | Codes Q0478 and Q0479 added to the Billing/Coding section (mco) |